NPIMap

Organization Active NPI

Avera Queen of Peace

Doing business as Avera Medical Group Orthopedics & Sports Medicine

  • Prosthetic/Orthotic Supplier
  • Mitchell, SD
National Provider Identifier
1710184569
Registry record updated Aug 20, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Prosthetic/Orthotic SupplierTaxonomy code 335E00000X
License
100-1023 Issued in SD
Legal business name
AVERA QUEEN OF PEACE
Doing business as
Avera Medical Group Orthopedics & Sports Medicine
Practice address
625 N Foster St
Suite 200
Mitchell, SD 57301-2969
Phone
(605) 996-3963
Fax
(605) 996-0718
NPI assigned
Jun 27, 2007
Last updated
Aug 20, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 20, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Douglas Ekeren
Title
President/Ceo
Phone
(605) 668-8322

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Prosthetic/Orthotic Supplier 335E00000X 100-1023 SD Primary

Addresses

Primary practice location

625 N Foster St
Suite 200
Mitchell, SD 57301-2969

Mailing address

625 N Foster St
Suite 200
Mitchell, SD 57301-2969
Phone (605) 995-2000

Other identifiers 1

IdentifierTypeStateIssuer
0100130MedicaidSD

Other names 1

  • Avera Medical Group Orthopedics & Sports Medicine Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SD

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100930071753 SD DME Supplier - Physician - Orthopedic/Orthopedic Surgery 9335050806 Practice locations: Mitchell, SD

Other NPIs with the same Medicare PAC ID 11

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Avera Queen of Peace Ho29 organizations share this tax ID, including this one

Other organizations with this tax ID 28

Organizations that report the same tax identification number in the National Provider Directory.

View all 28

Locations

625 N Foster St
Ste 200
Mitchell, SD 57301
Phone (605) 996-1800

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Avera Weskota Memorial Medical CenterWessington Springs, SD, CCN 43Z324 Hospital Operational/Managerial Control Jun 1, 2000

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

  • Avera Queen of Peace

    dba Avera Weskota Memorial Medical Center Swing Bed Program

    • Medicare Defined Swing Bed Hospital Unit
    • Wessington Springs, SD
    • NPI 1942205646

    Operational/Managerial Control

    CMS ownership

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1182902400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1597881600000",
    "number": "1710184569",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "625 N FOSTER ST",
            "address_2": "SUITE 200",
            "city": "MITCHELL",
            "state": "SD",
            "postal_code": "573012969",
            "telephone_number": "605-995-2000",
            "fax_number": "605-995-2441"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "625 N FOSTER ST",
            "address_2": "SUITE 200",
            "city": "MITCHELL",
            "state": "SD",
            "postal_code": "573012969",
            "telephone_number": "605-996-3963",
            "fax_number": "605-996-0718"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AVERA QUEEN OF PEACE",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-06-27",
        "last_updated": "2020-08-20",
        "certification_date": "2020-08-20",
        "status": "A",
        "authorized_official_last_name": "EKEREN",
        "authorized_official_first_name": "DOUGLAS",
        "authorized_official_title_or_position": "PRESIDENT/CEO",
        "authorized_official_telephone_number": "605-668-8322"
    },
    "taxonomies": [
        {
            "code": "335E00000X",
            "taxonomy_group": "",
            "desc": "Prosthetic/Orthotic Supplier",
            "state": "SD",
            "license": "100-1023",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0100130",
            "state": "SD"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Avera Medical Group Orthopedics & Sports Medicine",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Avera Medical Group Orthopedics & Sports Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mitchell, SD

Sources for this page

Verify at the official NPI Registry.